Online ISSN : 1687-8329

    




Quick Search 
 
Author  
Year    
Title  
Vol:  

 
 
January2011 Vol.48 Issue:      1 Table of Contents
Full Text
PDF


Personality Trait and Coping Strategies in Multiple Sclerosis: Neuropsychological and Radiological Correlation

Mona AF Nada1, Shireen M Abd El-Mawella2, Hoda A Bayoumy2, Mohamed Nasr I El Sirafy3

 

Departments of Neurology1, Psychiatry2, Cairo University; Radio-diagnosis3, Alexandria University; Egypt

 



ABSTRACT

Background: Personality trait represents one of the major factors influencing different aspects in quality of life and treatment compliance in multiple sclerosis. Objective: Explore personality changes and coping strategies and detect their relation with subcortical brain atrophy in multiple sclerosis. Methods: Forty multiple sclerosis patients, compared to 20 healthy matched controls, were evaluated by Mini-mental State Examination, Quality of life questionnaire, the Eysenck Personality Questionnaire, Hospital Anxiety and Depression Scale and Coping Processes Scale. Bicaudate ratio was measured from MRI FLAIR images to measure subcortical brain atrophy. Results: Progressive MS patients were older (39.39±6.94 vs. 29.23±7.72; P<0.01), and more disabled than remitting relapsing subjects (mean EDSS 5.9±1.2 versus 4.3±0.8). A highly statistically significant difference (p<0.01) was found between MS and control groups as regards coping mechanisms dealing with problem source where patients showed low score in exercite restrain (37.5%) compared to control group (6.7%). There was a statistically significant difference (p<0.05) in positive reinterpretation being higher in MS group (37.5%) compared to control group (10%). Psychoticism was more frequent in patients when compared to control. Bicaudate ratio was positively correlated with age, disease duration, severity and type of multiple sclerosis while it was inversely correlated with progression index. No correlation was detected between bicaudate ratio and personality trait. Conclusion: It is important to move from medical focus alone to include personality trait rehabilitation and programs with more problem-focused coping strategies with MS to help patients adjust to their illness. [Egypt J Neurol Psychiat Neurosurg.  2011; 48(1): 71-78]

 

Key Words: Multiple sclerosis; Personality trait; Coping strategies; Bicaudate ratio.

 

 

Correspondence to Mona AF Nada. Department of Neurology, Cairo University, Egypt.

Tel.: +20189288848      Email: Mona_a_nada@yahoo.com




INTRODUCTION

 

Multiple sclerosis (MS) is a heterogeneous disease that has significant cognitive and neuropsychological sequel1 beside physical disabilities. Although the cognitive and affect disorders in MS are well characterized, personality changes or its neurofunctional correlation are less investigated2,3.

Personality trait represents one of the major factors affecting psychological functioning; thus it influences different aspects in quality of life and treatment compliance. Personality characteristics may influence brain activity and adaptation and coping to illness and conversely is affected by neurological diseases4. Changes of personality and behavior have been suggested to be due to malfunctioning of certain brain areas e.g. prefrontal cortex (PFC) and amygdale5.

Brain atrophy has emerged as a useful surrogate marker of disease involvement in MS6. It has been suggested that atrophy in MS represents destructive and irreversible pathologic processes, making it a more reliable indicator of disease progression than the nonspecific T2 lesion load assessment7.

The Bicaudate ratio (BCR) is a reliable quantitative and readily obtainable measure of subcortical atrophy that can be performed without complex computer-assisted techniques from conventional brain magnetic resonance imaging (MRI)8.

The present work has dual aims: 1) To explore personality trait present and coping strategies used in MS and 2) To investigate the relation between personality trait and subcortical brain atrophy using bicaudate ratio.

 

PATIENTS AND METHODS

 

Study Design and Selection

This study is a prospective case-control study that included 40 Egyptian MS patients (24 females, 16 males) and 20 healthy controls (12 female, 8 males) from the general population who were age, sex and education matched. All patients who have definite MS according to McDonald criteria9 and its revision10 were recruited from inpatient Neurology Department, Cairo University Hospital from August 2008 to July 2009 after taking written consent. Patients were selected to be in steroid free period for at least 1 month from the study and are not in relapse for at least 1 month from the study. Exclusion criteria were: 1) Age < 18 years 2) Patients with cognitive impairment assessed by mini-mental state examination, 3) Concomitant therapy with antidepressant, psychoactive drugs or steroids 4) Presence of concurrent psychiatric disorders 5) Family history of psychiatric disorders 6) Alcohol consumption 7) Other medical or neurological diseases.

 

Methods

Patients were subdivided in two groups according to Lublin and Reingold11: Remitting relapsing MS (RRMS) group (22 patients) and primary progressive MS (PPMS) group (18 patients).

 

All patients were subjected to:

1.            Thorough clinical assessment: detailed history taking, clinical and neurological examination.

2.      Clinical Rating Scales: The Kurtzke Expanded Disability status scale (EDSS)12 & progression index (PI) were used to quantify disability and disease progress. Patients were classified to patients with minimal disability (EDSS ≤3) & moderate or severe disability (EDSS > 3). The PI corresponds to the ratio between EDSS and disease duration in years.

3.            Neuropsychological assessment:

I.       Mini-mental State Examination (MMSE)13: A score of < 24 is considered impairment of cognitive functions and was a criterion for exclusion.

II.     Quality of life (QoL) questionnaire14: Consists of 30 questions to assess somatic, cognitive, affective, social, economic and ego problems. Each item was scored from 0 to 2 (0= bad response and 2= good response). Results were calculated by multiplying the sum of each domain by 4 to obtain percentage for QoL (100% = better QoL).

III.    Hospital Anxiety and Depression Scale15: A self-assessment scale that includes 14 statements; 7 for each subscales. Scoring of each item the scale was done from 0 to 3 (0 = good response, 3=bad response) with minimum subscore=0 and maximum subscore=21. Score ≤ 7=absence; 8-10= doubtful, ≥ 11= definite anxiety or depression. 

IV.    Coping Processes Scale16: Assesses different coping mechanisms that could be used to deal with stressful situations. It is classified into 5 categories as follows; I: mechanism dealing with source of a problem (active coping and exercite restrain), II: behavioral strategy to decrease emotional reaction to stress (helplessness and emotional discharge), III: cognitive activities dealing with problem trying to solve it (positive reinterpretation and denial), IV: cognitive processes dealing with emotional side of a problem (acceptance, mental disengagement and wishful thinking) and V: mixed behavioral and cognitive mechanisms (information & social support & turning to religion).  It is a self rated scale. Each one of the 11 coping processes has certain phrases and each phrase takes score from 1 to 4 then the total score for each process is calculated. The normal cut off value ranges from 35-65 where low score is <35 and high score is >65.

V.     The Eysenck Personality Questionnaire (EPQ)17:  It is used to assess personality trait and is formed of 99 questions. It is a reliable research tool that is validated by criterion analysis. Disadvantage of the EPQ is that it asks yes/no questions which forces sometimes inaccurate response. It is used to assess neuroticism, psychoticism, introversion/extroversion, criminality and lie scale. Each one of the 5 dimensions has certain questions and each question takes score then a total score for each dimension is calculated.

4.      Neurophysiologic assessment: All the 40 MS patients showed electrophysiological i.e. visual evoked potential, somatosensory and brainstem auditory evoked potentials, findings that helped in confirming the diagnosis of MS according to McDonald’s criteria9,10.

5.      Conventional magnetic resonance imaging (MRI) of the brain: MRI was performed for all participants using Phillips Intera® Scanner on1.5 Tesla, with the results of T1-, T2-weighted spin echo images and FLAIR pulse sequences obtained. Barkhof criteria18 was used to fulfill radiological criteria for definite multiple sclerosis according to McDonald’s Criteria10. Bicaudate ratio was measured from FLAIR axial slice where the heads of the caudate nuclei were most visible and closest to one another19. It is the ratio of the intercaudate distance to the brain width along the same line thus measuring subcortical atrophy8.

 

Statistical Methods

Data were statistically described in terms of range, mean ± standard deviation (± SD) and percentages when appropriate. Comparison of quantitative variables between the study groups was done using Student t test for independent samples in comparing 2 groups when normally distributed and Mann Whitney U test for independent samples when not normally distributed. Comparison of age was done using one-way analysis of variance (ANOVA) test with posthoc multiple 2-group comparisons. For comparing categorical data, Chi-square (c2) test was performed. Exact test was used instead when the expected frequency is less than five. A probability value (p value) less than 0.05 was considered statistically significant. All statistical calculations were done using computer programs Microsoft Excel 2003 (Microsoft Corporation, NY, USA) and SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 15 for Microsoft Windows.

 

RESULTS

 

Participants’ characteristics: Forty Egyptian MS patients (24 female and 16 males) were recruited for this study. Their demographic data and clinical parameters are presented in Table (1).

Patients with PP MS were older (39.39±6.94 vs. 29.23±7.72; p<0.01) and more disabled than RR subjects (mean EDSS 5.9±1.2 vs. 4.3±0.8). There was no statistically significant difference (p<0.05) between the 3 studied groups as regards age, sex and MMSE scores as they were selected to be matched.

Quality of life: MS patients had statistically significant (p<0.01) poorer QOL with affective problems being the most affected aspect when compared with controls.

Coping Processes Scale: There was a highly statistically significant difference (p<0.01) between MS and control groups as regards coping mechanisms dealing with the source of a problem where patients showed low score in exercite restrain (37.5%) compared to controls (6.7%)). There was a statistically significant difference (p<0.05) in positive reinterpretation being higher in MS group (37.5%) compared to control group (10%) (Table 2).

Personality trait using EPQ: There was a highly statistically significant difference between MS and control groups as regards lie scale (p<0.01) and a statistically significant difference as regards psychoticism and criminality (p<0.05). On the other hand, neuroticism showed higher score in control group (33%) compared to (18%) MS patients with non statistical difference (P>0.05) (Table 3).

Comparison between RR and PP MS patients: Forty five percent of the MS patients (RR and PP) had definite anxiety and 52.5% had definite depressive symptoms. No statistically significant difference was found when comparing the two MS groups regarding anxiety or depression scores, yet 66.7% of PP MS had definite depression compared to 40.9% of RR MS patients (data not displayed).

QoL was poor in both RR and PP MS groups with non significant difference. Although all coping strategies didn’t show significant difference in the 2 MS groups, yet turning to religion was normal & occurred in all MS patients (Table 4). Also, there was no significant difference between personality trait in RR and PP MS (Table 5). When correlating between coping strategies and personality trait, there was positive correlation between psychoticism and denial (r=0.342, p=0.031) and between criminality & both helplessness (r=0.329, p=0.038) and wishful thinking (r=0.40, p=0.011). No other correlations were detected.

Bicaudate ratio: Bicaudate ratio showed a highly statistically significant difference (p=0.000) between control and MS groups (both types) (Mean 0.07±0.01 vs. 0.11±0.02 respectively) thus identifying subcortical atrophy in MS group. A statistically significant difference (p=0.014) was found when comparing mean BCR in PP group (0.12±0.025) and RR group (0.09± 0.015), where PP had more subcortical brain atrophy than RR group. There was a highly statistically significant positive correlation between BCR and age of patients, age at onset & disease duration. There was a highly statistically inverse correlation between BCR and progression index (r -0.451, P=0.003). BCR didn’t show statistical correlation with EPQ (Table 7).


 

 

Table 1. Demographic Data and Clinical Parameters in the Two MS Groups.

 

 

MS type

Sex

Age

Age at onset

Dse duration (years)

PI

EDSS

MMSE

F

M

(Mean±SD)

(Mean±SD)

(Mean±SD)

(Mean±SD)

(Mean±SD)

(Mean±SD)

PP (N= 18)

8

10

39.39±6.94

30±5.12

9.44±3.71

0.72±0.3

5.9±1.2

29.61±0.98

RR (N=22)

16

6

29.23±7.73

24.82±5.99

4.41±2.67

1.33±0.74

4.3±0.8

29.18±1.53

Total (N=40)

24

16

33.8±8.91

27.15±6.13

6.67±4.03

1.05±0.65

4.96±1.12

29.37±1.31

DSE Disease, EDSS Expanded disability status scale, F female, M male, MMSE  Mini-mental status examination, MS Multiple sclerosis, PI Progression index, PP Primary Progressive, RR Remitting Relapsing

Table 2. Comparison between MS & Control Group as Regards Coping processes Scale.

 

Scales

Patients group

Control group

P value

No

%

No

%

40

100

30

100

Helplessness

Low

1

2.5

0

0

0.551

Normal

33

82.5

27

90

High

6

15

3

10

Mental disengagement

Low

0

0

0

0

0.678

Normal

37

92.5

26

86.7

High

3

7.5

4

13.3

Seeking out of Information & social support

Low

3

7.5

4

13.3

0.678

Normal

37

92.5

26

86.7

High

0

0

0

0

Positive reinterpretation

Low

1

2.5

3

10

0.021*

Normal

24

60

24

80

High

15

37.5

3

10

Wishful thinking

Low

6

15

2

6.7

0.497

Normal

34

85

28

93.3

High

0

0

0

0

Turning to religion

Low

0

0

3

10

0.148

Normal

40

100

27

90

High

0

0

0

0

Emotional discharge

Low

2

5

0

0

0.432

Normal

29

72.5

24

80

High

9

22.5

6

20

Acceptance

Low

7

17.5

6

20

0.668

Normal

32

80

24

80

High

1

2.5

0

0

Exercite restrain

Low

15

37.5

2

6.7

0.007**

Normal

25

62.5

28

93.3

High

0

0

0

0

Denial

Low

0

0

0

0

0.142

Normal

31

77.5

28

93.3

High

9

22.5

2

6.7

Active coping

Low

6

15

3

10

0.797

Normal

34

85

27

90

High

0

0

0

0

p>0.05= non-significant, * Significant at p<0.05 **Significant at p<0.01

 

 

Table 3. Comparison of Personality Trait in MS and Control Groups.

 

EPQ

MS group

Control group

P value

No

%

No

%

40

100

30

100

Psychoticism

Normal

17

42

20

67

0.04*

Significant

23

58

10

33

Neuroticism

Normal

33

82

20

67

0.13

Significant

7

18

10

33

Introversion

Normal

39

97

27

90

0.41

Significant

1

3

3

10

Lie

Normal

10

25

21

70

0.001**

Significant

30

75

9

30

Criminality

Normal

21

53

24

80

0.03*

Significant

19

47

6

20

EPQ Eysenck personality questionnaire,

p>0.05= non-significant, * Significant at p<0.05 **Significant at p<0.01

 

 

Table 4. Comparison between Results of Coping Process Scale in PPMS and RR MS Groups.

 

 

MS type

P Value

PP

RR

No.

%

No.

%

18

100

22

100

Helplessness

Low

0

0

1

4.5

0.64

Normal

15

83.3

18

81.8

High

3

16.7

3

13.6

Mental disengagement

Normal

17

94.4

20

90.9

0.67

High

1

5.6

2

9.1

Seeking out of information and social

Low

2

11.1

1

4.5

0.43

Normal

16

88.9

21

95.5

Positive reinterpretation

Low

0

0

1

4.5

0.66

Normal

11

61.1

13

59.1

High

7

38.9

8

36.4

Wishful thinking

Low

2

11.1

4

18.2

0.53

Normal

16

88.9

18

81.8

Turning to religion

Normal

18

100

22

100

0

Emotional Discharge

Low

1

5.6

1

4.5

0.99

Normal

13

72.2

16

72.7

High

4

22.2

5

22.7

Acceptance

Low

3

16.7

4

18.2

0.64

Normal

15

83.3

17

77.3

High

0

0

1

4.5

Exercite of restrain

Low

4

22.2

11

50

0.07

Normal

14

77.8

11

50

Denial

Normal

13

72.2

18

81.8

0.47

High

5

27.8

4

18.2

Active copying

Low

4

22.2

2

9.1

0.25

Normal

14

77.8

20

90.9

MS Multiple sclerosis, PP Primary Progressive, RR Remitting Relapsing

p>0.05= non-significant

 

Table 5. Difference between Personality Trait using EPQ in PPMS and RRMS.

 

Eysenck personality questionnaire

MS type

P Value

PP

RR

No.

%

No.

%

18

100

22